Since the introduction of early intervention services, 40-60% of people experiencing their first episode of psychosis have made a full or partial recovery (Craig et al., 2004). However, some people continue to not respond well with routine early intervention services and still have problems in their social functioning. This can lead to long-term social difficulties, such as withdrawal, isolation, and lack of integration into the community.

Traditional Cognitive Behavioural Therapy (CBT) is recommended by the National Institute of Health and Clinical Excellence (NICE) for people with psychosis and has been demonstrated to be effective in helping with the symptoms of psychosis (NICE, 2014; Shepherd, 2014; Wykes et al, 2008). However, the traditional CBT approach does not explicitly aim to improve social functioning, which is extremely important to the recovery needs of people experiencing psychosis (Pitt et al, 2007). In particular, gaining meaningful employment, accessing education, spending time with friends and family, are important.

This study aimed to see if a social recovery CBT intervention, delivered within early intervention teams, could help improve social activity for people experiencing psychosis.

Social recovery is important to people with psychosis and can be an unmet need in current early intervention services.

Methods

This study is a single-blind randomised controlled trial in four early intervention teams (Birmingham, Lancashire, Norfolk and Suffolk). Participants were people with psychosis who had been with early intervention services for 12 to 30 months, had current psychotic symptoms (operationally defined by the PANSS (Kay et al, 1987) score ≥4 ), and difficulties in social functioning (operationally defined by ≤ on the Time Use Survey; Gershuny, 2011).

Participants were randomised to either:

The social recovery CBT intervention plus early intervention service,

Or early intervention services only (usual treatment).

Therapeutic intervention

The intervention was social recovery CBT, which was delivered in three stages:

Development of a detailed assessment with a particular focus on behaviours, therapeutic engagement and the development of a formulation, and identification of a problem list.

Results

Quality of data

Missing data for the primary outcome was low post-therapy (7%) and follow-up (16%) demonstrating acceptable rates. Higher rates of missing data was reported for other secondary measures such as the PANSS (20% post-therapy and 35% at follow-up), which may demonstrate a risk of bias on this outcome.

Sample

155 participants were randomly allocated to either receive CBT social recovery therapy (n=76) or early intervention services alone (n=79). Baseline characteristics were similar in both groups. The majority of the sample were male, white British, had English as a first language, and were single.

Therapy

Participants received an average of 16.49 sessions, and 81% of participants received an adequate ‘dose’ of therapy. The researchers reported that therapists had excellent fidelity to the treatment model. Seven participants dropped out of therapy and seven did not receive an adequate dose.

Main findings

The primary outcome of time in structured activity was significantly higher by 8.1 hours in the group that had social recovery CBT compared to the control group post-therapy, but this improvement was not maintained at follow-up.

Constructive economic activity (time in employment) also improved post-therapy for the social recovery CBT group (compared to the control group), but this was not maintained at follow-up

All other outcomes showed no benefit for the social recovery CBT intervention with the exception of hope at follow-up.

In the short-term, social recovery CBT led to more structured activity and time in employment, but these gains were not maintained at follow-up.

Conclusions

Social recovery CBT demonstrated improvements in structured activity post-therapy over usual treatment, but this was not maintained at follow-up. All secondary outcomes, except for hope at follow-up, did not demonstrate any significant improvements for social recovery CBT. The authors state that it may be the high level of missing data which had impacted on the findings.

Strengths and limitations

Strengths

The study followed best practice procedures, for example described by Consolidated Standards of Reporting Trials (CONSORT; Schulz et al, 2010) for conducting a trial which improved the reliability and validity of results. This included; prospectively publishing the research protocol, transparent reporting of results, following good clinical practice guidelines, recruiting from a variety of sites, participants being randomly allocated to conditions by people external to the research team, researcher assistants being blind to allocation, blind break monitoring, and use of intention to treat analysis.

The researchers were also able to recruit a vulnerable group of people with moderate to severe difficulties in their social functioning.

Limitations

The prospective protocol did not state at what time point (post-therapy or follow-up) the primary and secondary outcomes would be examined

After publishing the protocol, but prior to the study commencing, the authors chose to look at the primary outcome of structured activity use at post-therapy (9 months) as their primary outcome

Additional secondary outcome were added that were not on the original protocol. However, the authors of the study were transparent about this

Another potential limitation is the missing data at follow-up, which is likely to increase the risk of bias in the study findings.

Implications for practice

This study provides some evidence for focusing on social recovery in people receiving care from early intervention services. It shows that people experiencing psychosis who also struggle with social functioning can and are willing to engage in a therapy that aims to improve their activity levels. It also demonstrates that social recovery is an important issue that participants wanted to talk about and focus on in therapy.

Social functioning is an important component of recovery that should be considered in early intervention in psychosis services.

Conflicts of interest

Lisa is currently a post-doctoral research fellow, which is funded by the National Institute of Health Research (NIHR) Higher Education England North Central East London (HEENCEL) Collaboration in Leadership and Applied Health Research and Care (CLAHRC).

Lisa is a Principal Clinical Psychologist working within acute psychiatric inpatient services within the North East London Foundation Trust. She is also a Lecturer in Clinical Psychology on the University of Essex Doctorate in Clinical Psychology programme. Lisa has been working clinically with people experiencing long-term mental health difficulties (in particular psychosis) for over 10 years. She has always incorporated research within her professional practice. Her research interests are in developing psychological therapies for people who experience psychosis and are also in acute crisis.

[…] Can social recovery therapy improve social functioning in psychosis? Lisa Wood wrote about the SUPEREDEN3 trial, which found that in the short-term, social recovery CBT led to more structured activity and time in employment, but these gains were not maintained at follow-up. Lisa felt that this study provides some evidence for focusing on social recovery in people receiving care from early intervention services. It shows that people experiencing psychosis who also struggle with social functioning can and are willing to engage in a therapy that aims to improve their activity levels. It also demonstrates that social recovery is an important issue that participants wanted to talk about and focus on in therapy. […]